Australia should be prioritising home care services rather than residential aged care, the royal commission heard on Monday.
Yet more than 100,000 Australians are still waiting to receive the level of care they have been assessed as needing, and the regulator has decreased the number of provider inspections, despite the steady increase in the number of home care providers.
Counsel Assisting the Royal Commission into Aged Care Quality and Safety, Peter Gray QC, said Australia has one of the highest rates of its population living in residential aged care of any country in the world.
“Over 6% of people in Australia aged 65 or over live in residential aged care facilities, the second highest in the OECD after Lithuania,” Mr Gray said.
“And an astonishing figure of nearly 19% of people in Australia aged 80 or over live in residential aged care facilities, the highest currently or recently reported percentage in the OECD,” he said.
By comparison, in Canada 12 per cent of those over 80 live in residential care, in Scandinavia the figure is 13 per cent, and in New Zealand 14 per cent.
Mr Gray outlined the advantages of home care, including the overwhelming preference for Australians to remain living independently at home for as long as possible.
Flinders University research shows that the “overwhelming preference of the vast majority” of Australians is to remain independent and living at home. A “significant majority (72%)” said they would be willing to pay a co-contribution fee to remain at home rather than move into residential aged care, Mr Gray said.
The pandemic is likely to “reinforce people’s general preference” to continue living at home as they grow older, he said.
Home care services also tend to keep people well and independent for longer.
For each hour of additional home care per week, research has shown there is a 6 per cent decrease in the chance the person will ever go into residential aged care.
‘Home’ provides a sense of “familiarity, comfort and security” that supports physical and mental wellbeing.
Moving into residential care also makes many people “fearful”, due to the loss of independence and their previous experiences with institutional care.
Mr Gray noted some of the negatives of home care too.
An effective home care service depends on the availability of information and the ability of people to be able to access and interpret that information. In reality, this is not always possible.
Home care also depends on services being available in all areas, which can be a problem in Australia, especially in rural and remote areas.
Home care package numbers are also capped, meaning more than 10,000 consumers are missing out on receiving the level of care they have been assessed as needing. “More than half the people who need packages for more complex and intensive levels of home care are currently waiting for their assessed package, and are likely to wait more than 12 months for it or miss out altogether,” Mr Gray said.
And consumers are not using all their packages, leaving providers with billions in ‘unspent funds’, Mr Gray observed.
The number of Australians receiving home care packages has increased significantly in recent years.
As of 30 June 2019, there were about 106,000 people receiving home care packages, a 16 per cent increase from the end of the 2017-18 financial year.
The number of packages assigned since then has increased markedly. By December 2019, 145,320 people had access to a package, and as of 31 March 2020, 151,958 people had been allocated a home care package.
Mr Gray says the goal is for every Australian to have access to the home care services they have been assessed as needing.
Mr Gray said the government does not systematically collect information about home care providers and the services they deliver, which he called an “abdication of system management responsibility by government.
“It must change,” he said.
A strong aged care workforce is fundamental to a successful home care system, Mr Gray said.
Home care policies and practices must support a “virtuous cycle” for aged care workers, whereby “good employment, attractive wages and working conditions, supportive management and an empowering work culture, collaborative teams, high quality and relevant education and training, and high job satisfaction among care workers underpin high quality, person-centred care.”
Mr Gray said he was concerned home care providers do not have the capability to provide the services that will be required of them in the years ahead.
“The capability of home care providers is presently inadequate and serious enhancement of capabilities will be needed to provide the uncapped, demand-driven home care services of the future,” he said.
Research by independent aged care accountancy firm, StewartBrown, shows only a small proportion of home care packages are spent on nursing services. On average, less than 0.5 per cent of total charges in low care packages are spent on nursing care, and up to 2 per cent of Level 4 packages, on average.
“The picture presented by the data raises real concerns that inadequate clinical experience is being brought to bear in the care management of people with complex needs,” Mr Gray said.
Mr Gray suggested care coordinators should be qualified and experienced registered nurses or allied health professionals and that there be a minimum contact time provided as part of a home care package.
Mr Gray noted that home care regulation is “very challenging”.
“It is delivered behind closed doors in the private homes of hundreds of thousands of individuals,” he said.
Regulation by the Aged Care Quality and Safety Commission must be bolstered, Mr Gray said.
The Aged Care Quality and Safety Commissioner herself, Janet Anderson, has told the royal commission, “At the moment I’m not convinced that our regulatory gaze in home care is as strong as it needs to be.”
Alarmingly, there has been a decrease in the number of regular inspections of home care services.
On average there have been 25 quality reviews and 66 assessment contacts for home care providers each quarter during the three quarters between 1 July 2019 and March 2020.
However, there were 181 quality reviews and 291 assessment contacts for home care providers in the quarter 1 April 2019 to 30 June 2019, figures that were approximately equal with prior quarters.
The Aged Care Quality and Safety Commission gave the following reasons for the decline: high turnover of assessor staff, the new Quality Standards meaning it takes longer to assess providers, particularly the evidence gathering and report writing aspects of the role, and the higher number of non-compliances identified in residential aged care.
Mr Gray said if Australia can “get homecare right”, it could alleviate some of the financial pressures on the aged care system and ensure the sector’s long-term sustainability.
He proposed the level of funding for home care be increased so that it is equal to the amount the person would have received had they gone into residential aged care.
“Home care is cheaper than residential care on a per capita basis, and currently much cheaper on an aggregated basis too,” he said.
“If people don’t get the home care they need, they deteriorate, their quality of life is diminished, they will be more likely to have to go hospital, and they are more likely to lose their capacity for independent living and enter residential care.
“Thus the current delays and failures to provide assessed care are not only inhumane, but have obvious and serious systemic consequences that are damaging to the aged care system, the healthcare system and the government’s budget.
“Hospital admissions and residential care are far more expensive to the public purse than timely support and care provided in people’s own homes.
“So a shift in the direction of resources toward home care has the potential to make the system more economically sustainable in the longer term,” Mr Gray said.